Identifying Healthcare-associated Infections

Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance

To standardize the classification of an infection as present on admission (POA) or a
healthcare-associated infection (HAI), the following objective surveillance definitions and
guidance are used for NHSN surveillance:

7-day Infection Window Period

Date of Event
POA
HAI
14-day Repeat Infection Timeframe (RIT)
Secondary Bloodstream Infection Attribution Period
Pathogen Assignment Guidance

The intention of this approach is to align criteria and definitions and decrease subjectivity
while maintaining epidemiologic standardization and clinical relevance. A variety of
scenarios to include repeat infections of the same type, concurrent infections of differing
types, and pathogen assignment in multi-pathogen infections are addressed.
Notes:

Infection window period, POA, HAI, and RIT definitions do not apply to SSI, VAE,
or LabID Events.
Date of Event, as defined in this chapter, does not apply to VAE or LabID Events;
Secondary BSI attribution period, as defined in this chapter, does not apply to SSI,
VAE, LabID or primary BSI events.
o SSI surveillance utilizes a 30 or 90 day surveillance period. Since the
Infection Window Period and RIT do not apply, the secondary BSI attribution
period, by name, also cannot apply. However, a 17-day period that includes
the date of SSI event, 3 days prior and 13 days after, is still used to attribute a
BSI as secondary to an SSI.
o Specific guidance can be found in the VAE protocol for secondary BSI
attribution.
o A primary BSI/CLABSI by definition can never have a secondary BSI.
Organisms belonging to the following genera are typically causes of communityassociated infections and are rarely or are not known to be causes of healthcareassociated infections, they are excluded, and cannot be used to meet any NHSN

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definition: Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus

and Pneumocystis.

If the date of culture collection is on or after the date the patient is declared brain
dead AND the patient is being supported for organ donation purposes, the event
should not be reported as an HAI. For VAE surveillance, if the date of event (date of
onset of worsening oxygenation) is on or after the date the patient is declared brain
dead AND the patient is being supported for organ donation purposes, the event
should not be reported as a VAE.

SSI
N/A
Yes
N/A
N/A
N/A
*

LabID

VAE
Not
Applicable

Infection Window Period

Date of Event
POA
HAI
Repeat Infection Timeframe (RIT)
Secondary BSI Attribution Period

Not
Applicable

Table 1: Definition Application

BSI
Yes
Yes
Yes
Yes
Yes
N/A

*See SSI specific guidance

N/A=Not Applicable

Observation Patients in Inpatient Locations:

For purposes of NHSN surveillance, if an observation patient is sent to an inpatient location,
the patient must be included in infection surveillance, patient day, and device day counts.
The facility assignment of the patient as an observation patient or an inpatient has no bearing
in this instance for counting purposes. The patient is being housed, monitored, and cared for
in an inpatient location and therefore is at risk for acquisition of an HAI.
NHSN Infection Window Period:
The NHSN Infection Window Period is defined as the 7-days during which all site-specific
infection criteria must be met. It includes the day the first positive diagnostic test that is used
as an element of the site-specific infection criterion, was obtained, the 3 calendar days before
and the 3 calendar days after. For purposes of defining the Infection Window Period the
following are considered diagnostic tests:

laboratory specimen collection

imaging test
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procedure or exam
physician diagnosis
initiation of treatment

For site-specific infection criteria that do not include a diagnostic test, the first documented
localized sign or symptom that is used as an element of NHSN infection criterion should be
used to define the window (e.g., diarrhea, site specific pain, purulent exudate).
For example, when meeting GE using criterion 1, there is no diagnostic test as a part
of this site-specific infection criterion. A sign or symptom (diarrhea) must be used to
set the infection window period.

Infection Window Period

Table 2: Infection Window Period

3 days before
First positive diagnostic test
OR
First documented localized
sign and/or symptom in the
absence of a diagnostic test
3 days after

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Date of Event (Event Date):

The Date of Event is the date the first element used to meet an NHSN site-specific infection
criterion occurs for the first time within the seven-day infection window period.
An infection is considered Present on Admission (POA) if the date of event of the
NHSN site-specific infection criterion occurs during the POA time period, which is
defined as the day of admission to an inpatient location (calendar day 1), the 2 days
before admission, and the calendar day after admission. For purposes of NHSN
surveillance and determination of the Repeat Infection Timeframe (as defined below)
if the date of event is determined to be either of the two days prior to inpatient
admission, then the date of event will be hospital day 1.
An infection is considered a Healthcare-associated Infection (HAI) if the date of
event of the NHSN site-specific infection criterion occurs on or after the 3rd calendar
day of admission to an inpatient location where day of admission is calendar day 1.
Table 3: Date of Event and Classification Determination
Hospital Day
2 days before admit
1 day before admit
1
2
3
4
5

Date of Event
Assignment for RIT
Hospital Day 1
Hospital Day 1
Hospital Day 1
Hospital Day 2
Hospital Day 3
Hospital Day 4
Hospital Day 5

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Classification

POA

HAI

Identifying Healthcare-associated Infections

Table 4: Infection Window Period and Date of Event

(Patient age < 65)

Notes:
Acceptable documentation includes patient-reported signs or symptoms documented in
the chart by a healthcare professional (e.g., patients states measured fever > 38.0 C or
100.4 F, nursing home documents fever prior to arrival to the hospital, patient complains
of dysuria).
Physician diagnosis can be accepted as evidence of an infection only when physician
diagnosis is an element of the specific infection definition. For example, physician
diagnosis is not an element of any UTI criteria; therefore, physician diagnosis of a UTI
may not be used to satisfy POA status of a UTI.
Infections occurring in newborns with date of event on hospital day 1 or day 2 are
considered POA. Those with date of event on day 3 or later are HAI. This would include
infections acquired transplacentally (e.g., herpes simplex, toxoplasmosis, rubella,
cytomegalovirus, or syphilis) or as a result from passage through the birth canal (e.g.,
Group B Streptococcus).

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Reactivation of a latent infection (e.g., herpes zoster [shingles], herpes simplex, syphilis,
or tuberculosis) is not considered to be HAI.

Repeat Infection Timeframe (RIT):

The RIT is a 14-day timeframe during which no new infections of the same type are reported.
The RIT applies to both POA and HAI determinations. The date of event is Day 1 of the
14-day RIT. If criteria for the same type of infection are met within the 14 day RIT, a new
event is not identified or reported. Additional pathogens recovered during the RIT from the
same type of infection are added to the event.
The RIT will apply at the level of specific type of infection with the exception of BSI, UTI,
and PNEU where the RIT will apply at the major type of infection.
Specific Type Example:

Patients will have no more than one BONE infection in an RIT, but may have a
BONE and DISC in two overlapping RITs (specific type)

Major Type Examples:

Patients will have no more than one LCBI in an RIT (e.g., LCBI 1, LCBI 2, MBILCBI 1, etc.)
Patients will have no more than one PNEU in an RIT (e.g., PNU1, PNU2, PNU3)
Patients will have no more than one UTI in an RIT (e.g., SUTI, ABUTI)

The RIT applies during a patients single admission, including the day of discharge and the
day after, in keeping with the Transfer Rule. An RIT does not carry over from one
admission to another even if readmission is to the same facility.

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In the example below (Table 5), the Date of Event is hospital day 4. The 14-day RIT is
hospital day 4 through day 17. On hospital day 12, within the RIT, a urine culture with >
100,000 CFU/ml S. aureus is identified. The urine pathogen identified from the hospital day
12 culture is added to the originally identified infection on hospital day 4. Determination of
a new infection or continuation of ongoing infection is not required.

Table 5: Repeat Infection Timeframe

Notes:
A patient may have negative cultures during the RIT without impact on the RIT.
Do not change the device-association determination during the RIT.
o Example: A non-catheterized UTI is identified and initiates an RIT. During
the RIT, a Foley catheter is placed and more than 2 days later, still in the RIT,
another urine culture is collected and resulted as positive for > 100,000
CFU/ml with a different bacteria. Add this pathogen to the original UTI but
do not change the non-catheter associated UTI to CAUTI.

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Secondary BSI Attribution Period (Refer to Appendix 1, Secondary BSI Guide of the BSI
Event Protocol):
The Secondary BSI Attribution Period* is the period in which a positive blood culture must
be collected to be considered as a secondary bloodstream infection to a primary site
infection. This period includes the Infection Window Period combined with the Repeat
Infection Timeframe (RIT). It is 14-17 days in length depending upon the date of event.
For a bloodstream infection to be determined secondary to another site of infection, the blood
culture must be collected during the site-specific infection Secondary BSI Attribution Period
and satisfy one of the following (See Appendix 1: Secondary BSI Guide):
1. An organism identified from the site specific infection is used as an element to meet
the site-specific infection criterion, AND the blood specimen contains at least one
matching organism to that site specific specimen
OR
2. The positive blood specimen is an element used to meet the site-specific infection
criterion
*Note: SSI surveillance utilizes a 30 or 90 day surveillance period. Since the Infection
Window Period and RIT do not apply, the secondary BSI attribution period, by name, also
cannot apply. However, a 17-day period that includes the date of SSI event, 3 days prior and
13 days after, is still used to attribute a BSI as secondary to an SSI.

Exception:
Necrotizing enterocolitis (NEC) criteria include neither a site-specific specimen nor organism
identified from blood specimen, however an exception for assigning a BSI secondary to NEC
is provided.
A BSI is considered secondary to NEC if the patient meets one of the two NEC criteria AND
an organism identified from blood specimen collected during the secondary BSI attribution
period is an LCBI pathogen, or the same common commensal which is identified from two or
more blood specimens drawn on separate occasions collected on the same or consecutive
days.

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In the example below (Table 6), the Date of Event is hospital day 4. The 14-day RIT is
hospital day 4 through day 17. The Secondary BSI Attribution Period is the Infection
Window Period combined with the Repeat Infection Timeframe (RIT), 17 days in this
example. The blood culture collected on hospital day 10 has a matching pathogen to the site
specific culture used to meet SUTI definition, and therefore, a secondary BSI is identified.
Table 6: Secondary BSI Attribution Period

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In the example below (Table 7), the Date of Event is hospital day 4. The 14-day RIT is
hospital day 4 through day 17. The secondary BSI Attribution Period is 17 days in length.
The blood culture collected on hospital day 5 is used as an element to meet the PNU2
infection definition and therefore a secondary BSI is identified.

Table 7: Secondary BSI Attribution Period

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Pathogen Assignment Guidance:

The following provides guidance for reporting pathogens associated with site-specific
infections that are identified during the RIT or during the secondary BSI attribution period.

Additional pathogens recovered during the RIT from the same type of infection are added
to the event.
Report all site-specific pathogens before secondary BSI pathogens.
o SUTIs can only have two organisms entered according to NHSN application
rules. However, if yes is selected for the secondary BSI field, the third pathogen
field will become available for data entry.
BSI pathogens may be assigned to more than one infection source at the same time in the
following scenarios.
1) Secondary BSI pathogen assigned to two different site-specific infections (see
example 1)
OR
2) Secondary BSI pathogen assigned to a site-specific infection and assigned as
pathogen to a primary BSI event (see example 2).

Example 1:
K. pneumoniae is identified in a blood culture during the RIT of a SUTI with K.
pneumoniae. The patient is also recovering from COLO surgery performed at your
facility in the past week and now has:
o
o
o

Fever > 38.0 C

Abdominal pain, and
CT showing abdominal abscess

These three elements, when combined with a positive blood culture, meet IAB criterion
3b. If a facility includes both UTI and SSI (for COLO) in their monthly reporting
plan, an UTI and SSI would be reported, both with a secondary BSI and with
pathogen K. pneumoniae.
Note: SSI-IAB does not have an Infection Window Period or RIT. The secondary BSI
attribution period is 17 days in duration including the date of event, 3 days prior and 13
days after the date of event.

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Cont. Example 1

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Example 2:
On day 4 of hospital admission, S. aureus is identified in a blood culture
meeting the HAI, LCBI 1 criterion. On day 8 the patient has a fever > 38.0 C
and E. coli is identified in a urine culture meeting the SUTI definition. On
hospital day 13, a blood culture positive for E.coli is identified. Because the
blood culture occurs within both the LCBI RIT and the SUTI secondary
BSI attribution period, the pathogen, E.coli is assigned to both events.

Pathogens excluded from specific infection definitions (e.g., yeast in UTI, Enterococcus
spp. in PNEU) are also excluded as pathogens for BSIs secondary to that type of infection
(i.e., they cannot be added to one of these infections as a pathogen). The excluded
organism must be accounted for as either:
1) A primary bloodstream infection (BSI/CLABSI) (see example 3)
OR
2) A secondary BSI attributed to another primary infection (e.g., IAB, SINU, etc.),
in accordance with Appendix 1, Secondary BSI Guide of the BSI Event protocol
(see example 4)
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Example 3:
A SUTI with Enterococcus faecalis is identified and a subsequent blood culture
with yeast and E. faecalis is collected during the SUTI secondary BSI attribution
period. A BSI secondary to SUTI is identified. E. faecalis is already
documented as a pathogen, but the yeast will not be reported as a secondary
BSI pathogen, because yeasts are excluded as organisms in the UTI
definition. In this example, no other primary source of infection for which the
yeast BSI can be assigned as secondary is identified. Therefore a primary BSI
with yeast only is identified.
Note: The Enterococcus faecalis is not assigned as a pathogen for the primary
BSI because if an excluded organism had not been identified, a primary BSI
would not have been reported.

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Example 4:
A PNU2 with Acinetobacter baumannii cultured from blood is identified.
Note: the positive chest imaging result is the diagnostic test that is used to
define the infection window period. A subsequent blood culture with
Enterococcus faecalis and A. baumannii is collected during the secondary BSI
attribution period of this PNU2 event. Enterococcus faecalis will not be
reported as a pathogen for the PNU2, because Enterococcus spp. are
excluded as organisms in the PNEU definition. Another primary source of
infection, SUTI, is found and Enterococcus faecalis is assigned as a secondary
BSI pathogen.

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Determination of a secondary BSI to a primary site of infection does not set an RIT for all
subsequent BSIs. If a blood culture occurs during a site specific infections secondary BSI
attribution period and it cannot be used as an element to meet the infection definition or does not
have at least one matching pathogen to the site-specific infection culture used to meet the sitespecific infection criterion the BSI must be evaluated as a new BSI event (see example 5)

Example 5:
A SUTI with Enterococcus faecalis is identified and a blood culture with E.
faecalis collected on hospital day 11 within the SUTI secondary BSI
attribution period is also identified. On hospital day 15 (also within the SUTI
RIT and secondary BSI attribution period), a blood culture growing
Staphylococcus aureus is identified. Because the blood growing S. aureus
does not have at least one pathogen that matches the urine culture used to
meet the SUTI criterion the BSI cannot be attributed as secondary to the
SUTI. The BSI will need to be investigated as a new BSI event and either
assigned as a secondary BSI to another primary site of infection or determined
to be a primary BSI.
Note: The secondary BSI attribution period for a primary site of infection
does not establish a repeat infection timeframe for all subsequent BSIs.

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Cont. Example 5

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Location of Attribution:
The inpatient location where the patient was assigned on the date of event is the location of
attribution (see Date of Event definition).
Exception to Location of Attribution:
Transfer Rule: If the date of event is on the date of transfer or discharge, or the next day, the
infection is attributed to the transferring/discharging location. This is called the Transfer Rule
and examples are found in UTI, BSI and PNEU modules. Receiving facilities should share
information about such HAIs with the transferring location or facility to enable reporting.

Multiple Transfers:
In instances where a patient has been transferred to more than one location on the date of an
infection, or the day before, attribute the infection to the first location in which the patient
was housed the day before the infections date of event.
Example of multiple transfers within the transfer rule time-frame:

Locations
in which
patient was
housed

3/22
Unit A

3/23
Unit A
Unit B
Unit C

3/24
Unit C
Unit D
This is also the date of
event for a CAUTI. CAUTI
is attributed to Unit A since
Unit A was the first
location in which the
patient was housed the day
before the date of event.

Note: The complete set of CDC/NHSN HAI site-specific infection criteria, and the
comments and reporting instructions integral to the correct application of the criteria, can be
found in Chapter 17, CDC/NHSN Surveillance Definitions for Specific Types of Infections.

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